I wouldn't want you to think that general practice is all sickness, pain and disability. There's death, too. The other day a girl of about seven was brought to see me by her father. After we had dealt with the main problem he told me that she has been getting upset in the evenings. She cries and says that she is worried about things, such as the house being burgled or that she is going to die. A distant elderly relative is ill in hospital, but otherwise there has been nothing unsettling happening at home. She seems otherwise happy and is behaving normally. We had a little chat and she told me about some of her fears. I examined her heart and her lungs.
There was an interesting television programme the other night about memory. Research suggests that the reason we don't remember much that happens before we are five is because that is the age at which we develop a sense of self. Events prior to five are just random events that we observe but probably won't remember. Events after five are things that happen to us, they have a personal significance and so are much more likely to be remembered. From the age of about five until nine we gradually build up a picture of ourselves and our place in the world.
I discussed this with her and her father, saying that she is now working out her relationship with the world, and that includes coming to terms with the realisation that bad things may happen to her or her family and that they are all going to die one day. I think this is harder for children to cope with nowadays because news reporting on television is so emotional, with lengthy shots of grieving distressed people and presenters vying with each other to give the most harrowing report. The emphasis is frequently on how the events have happened to ordinary people in ordinary places. I reassured the girl that she looked very healthy and told her she is going to live for many years. I mentioned that one of my own children had similar fears at the same age, and I advised her father to encourage her to talk about her fears and give her lots of cuddles.
Her parents are separated and live apart, which I don't think is helping. It won't help her to see the world as a stable place and she may have some feelings of guilt about the separation. I didn't think it right to mention these thoughts.
I have also been doing some bereavement counselling. Last year I wrote about Simon, a man in his twenties supporting his much younger sister Janie who had a nasty form of cancer. Simon was more like a father than a brother to her, and the problem was always denial. Janie is not my patient so I have only had a distant view of events, but for a long time I tried to persuade Simon to face the truth a little more squarely, for his benefit as much as for Janie's. From his reports I could tell that Janie's consultant was trying to do the same thing, but he persisted in believing that there would always be a new course of treatment that could be tried. She has now died, and Simon is having difficulty coping. After all the busy-ness of attending hospital and arranging treatments he is left with nothing to do. It isn't fair that she has gone. He can't believe that he won't see her again. He needs to know that she is alright. And from a different perspective he is having to come to terms with our mortality, just like my seven-year-old patient.
I am doing my best to help him work out these thoughts and feelings, offering what I hope will be a little helpful explanation and suggestion. I know something of what he is feeling for I too have lost a child, but I have not mentioned this to him. I think it would in a sense be forcing my solution on him, and make light of his suffering - as though I were saying “that's happened to me too and I've got over it, so buck your ideas up and stop complaining”. Our grief is immense and personal, and only we can bear it.